Biomechanical evaluation of different medial column fixation patterns for valgus pilon fractures.

BACKGROUND: The purpose of this study was to perform a biomechanical analysis to compare different medial column fixation patterns for valgus pilon fractures in a case-based model. METHODS: Based on the fracture mapping, 48 valgus pilon fracture models were produced and assigned into four groups with different medial column fixation patterns: no fixation (NF), K-wires (KW), intramedullary screws (IS), and locking compression plate (LCP). Each group contained wedge-in and wedge-out subgroups. After fixing each specimen on the machine, gradually increased axial compressive loads were applied with a load speed of one millimeter per minute. The maximum peak force was set at 1500 N. Load-displacement curves were generated and the axial stiffness was calculated. Five different loads of 200 N, 400 N, 600 N, 800 N, 1000 N were selected for analysis. The specimen failure was defined as resultant loading displacement over 3 mm. RESULTS: For the wedge-out models, Group-IS showed less displacement (p < 0.001), higher axial stiffness (p < 0.01), and higher load to failure (p < 0.001) than Group-NF. Group-KW showed comparable displacement under loads of 200 N, 400 N and 600 N with both Group-IS and Group-LCP. For the wedge-in models, no statistical differences in displacement, axial stiffness, or load to failure were observed among the four groups. Overall, wedge-out models exhibited less axial stiffness than wedge-in models (all p < 0.01). CONCLUSIONS: Functional reduction with stable fixation of the medial column is essential for the biomechanical stability of valgus pilon fractures and medial column fixation provides the enough biomechanical stability for this kind of fracture in the combination of anterolateral fixation. In detail, the K-wires can provide a provisional stability at an early stage. Intramedullary screws are strong enough to provide the medial column stability as a definitive fixation. In future, this technique can be recommended for medial column fixation as a complement for holistic stability in high-energy valgus pilon fractures.

Plate fixation of inferior ramus in pubis-ischium ramus improves mechanical stability in Tile B pelvic injures: a cadaveric biomechanical analysis and early clinical experience.

BACKGROUND: Management of inferior ramus of the pubis-ischium ramus remains controversial, and related research is sparse. The main intention of this study is to describe the biomechanical and clinical outcomes of pubis-ischium ramus fractures in Tile B pelvic injuries and to identify the feasibility and necessity of fixation of the inferior ramus of the pubis-ischium ramus. METHODS: This study comprised two parts: a biomechanical test and a retrospective clinical study. For the biomechanical tests, Tile B-type pelvic injuries were modeled in six cadaver specimens by performing pubis-ischium osteotomies and disruption of the anterior and interosseous sacroiliac ligaments. The superior and/or inferior rami of the pubis-ischium ramus were repaired with reconstruction plates and separated into three groups (A, B, and C). Specimens were placed in the standing position and were loaded axially with two-leg support for three cycles at 500 N. The displacements of sacroiliac joints at osteotomy were measured with Vernier calipers and compared using statistical software. To investigate the clinical outcomes of this technique, 26 patients were retrospectively analyzed and divided into a superior ramus fixation group (Group D) and a combined superior and inferior ramus of the pubis-ischium ramus fixation group (Group E). The main outcome measures were time of operation, blood loss, postoperative radiographic reduction grading, and functional outcomes. RESULTS: In the vertical loading test, Group E showed better pelvic ring stability than Group D (P < 0.05). However, the shift of the sacroiliac joints was almost identical among the three groups. In our clinical case series, all fractures in Group E achieved bony union. Group E demonstrated earlier weight-bearing functional exercise (2.54 ± 1.45 vs 4.77 ± 2.09; P = 0.004), earlier bony union (13.23 ± 2.89 vs 16.55 ± 3.11; P = 0.013), and better functional outcomes (89.77 ± 7.27 vs 82.38 ± 8.81; P = 0.028) than Group D. The incidence of sexual dysfunction was significantly lower in Group E than that in Group D (2/13 vs 7/13; P = 0.039). Bone nonunion occurred in two patients in Group D, and two patients in Group E had heterotopic ossification. None of the patients exhibited wound complications, infections, implant failures, or bone-implant interface failures. CONCLUSIONS: Fixation of the inferior ramus of a pubis-ischium ramus fracture based on conventional fixation of the anterior pelvic ring is mechanically superior in cadaveric Tile B pelvic injury and shows rapid recovery, good functional outcomes, and low incidence of complications.

Highly extensile approach for comminuted ulna coronoid process fractures with mini-plate fixation: a case series of 31 patients.

BACKGROUND: For the treatment of coronoid process fractures, medial, lateral, anterior, anteromedial, and posterior approaches have been increasingly reported; however, there is no general consensus on the method of fixation of coronal fractures. Here, we present a highly-extensile minimally invasive approach to treat coronoid process fractures using a mini-plate that can achieve anatomic reduction, stable fixation, and anterior capsular repair. Further, the study aimed to determine the complication rate of the anterior minimally invasive approach and to evaluate functional and clinical patient-reported outcomes during follow-up. METHODS: Thirty-one patients diagnosed with coronoid fractures accompanied with a "terrible triad" or posteromedial rotational instability between April 2012 and October 2018 were included in the analysis. Anatomical reduction and mini-plate fixation of coronoid fractures were performed using an anterior minimally invasive approach. Patient-reported outcomes were evaluated using the Mayo Elbow Performance Index (MEPI) score, range of motion (ROM), and the visual analog score (VAS). The time of fracture healing and complications were recorded. RESULTS: The mean follow-up time was 26.7 months (range, 14-60 months). The average time to radiological union was 3.6 ± 1.3 months. During the follow-up period, the average elbow extension was 6.8 ± 2.9° while the average flexion was 129.6 ± 4.6°. According to Morrey's criteria, 26 (81%) elbows achieved a normal desired ROM. At the last follow-up, the mean MEPI score was 98 ± 3.3 points. There were no instances of elbow instability, elbow joint stiffness, subluxation or dislocation, infection, blood vessel complications, or nerve palsy. Overall, 10 elbows (31%) experienced heterotopic ossification. CONCLUSION: An anterior minimally invasive approach allows satisfactory fixation of coronoid fractures while reducing incision complications due to over-dissection of soft tissue injuries. In addition, this incision does not compromise the soft tissue stability of the elbow joint and allows the patient a more rapid return to rehabilitation exercises.

Distal Clavicle Fracture Repair Utilizing Plate and Suture-Button Fixation: Optimizing Intraoperative Fluoroscopy.

VIDEO AVAILABLE AT: https://ota.org/education/ota-online-resources/video-library-procedures-techniques/distal-clavicle-fracture-repair.

The Effects of Unitizing Nail-Plate Constructs in Distal Femur Fractures: A Biomechanical Study.

OBJECTIVES: To assess the biomechanical differences between linked and unlinked constructs in young and osteoporotic cadavers in addition to osteoporotic sawbones. METHODS: Intraarticular distal femur fractures with comminuted metaphyseal regions were created in three young matched pair cadavers, three osteoporotic matched pair cadavers, and six osteoporotic sawbones. Precontoured distal femur locking plates were placed in addition to a standardized retrograde nail, with unitized constructs having one 4.5 mm locking screw placed distally through the nail. Nonunitized constructs had seven 4.5 mm locking screws placed through the plate around the nail, with one 5 mm distal interlock placed through the nail alone. Cadaveric specimens were subjected to axial fatigue loads between 150 and 1500 N (R Ratio = 10) with 1 Hx frequency for 10,000 cycles. Sawbones were axially loaded at 50% of the ultimate load for fatigue testing to achieve runout, with testing performed with 30 and 300 N (R Ratio = 10) loads with 1 Hz frequency for 10,000 cycles. RESULTS: In young cadavers, there was no difference in the mean cyclic displacement of the unitized constructs (1.51 ± 0.62mm) compared to the non-unitized constructs (1.34 ± 0.47mm) (Figure 4A), (p = 0.722). In osteoporotic cadavers, there was no difference in the mean cyclic displacement of the unitized constructs (2.46 ± 0.47mm) compared to the non-unitized constructs (2.91 ± 1.49mm) (p =0.639). There was statistically no significant difference in cyclic displacement between the unitized and non-unitized groups in osteoporotic sawbones(p = 0.181). CONCLUSIONS: Linked constructs did not demonstrate increased axial stiffness or decreased cyclical displacement in comparison to unlinked constructs in young cadaveric specimens, osteoporotic cadaveric specimens, or osteoporotic sawbones.

Isolated Lateral Plating for Bicondylar Tibial Plateau Fractures: Factors Influencing Decision Making.

Lateral plating alone has been postulated as an alternative for fixation of bicondylar tibial plateau fractures in attempts to limit morbidity associated with dual plating. Characterization of fracture patterns that may facilitate lateral plating alone for bicondylar tibial plateau fractures is not well established. The authors analyzed radiographic and clinical outcomes of isolated lateral plating in patients with at least 6 months of follow-up. Of 56 patients identified, 37 (66%) had 41 AO Foundation (AO)/Orthopaedic Trauma Association (OTA) C1/C2 fractures with 19 (34%) presenting with 41 C3 fractures. Mean posteromedial articular fracture angle (PMAFA) was 69.9 degrees, with an average of 1.3 medial articular fragments. Only 16 patients (28%) had a PMAFA under 45 degrees. There were no cases of nonunion, and five patients (8.9%) developed wound infection during follow-up. Four patients (7.1%) experienced malreduction over three degrees, and eight patients (14.3%) experienced change in alignment over the follow-up duration, indicating some risk of inadequate fixation with this technique. (Journal of Surgical Orthopaedic Advances 33(2):088-092, 2024).

Experimental study on the biomechanical stability of complex acetabular fractures in the quadrilateral area: application of a dynamic anterior titanium-plate screw system.

BACKGROUND AND OBJECTIVE: Complex acetabular fractures involving quadrilateral areas are more challenging to treat during surgery. To date, there has been no ideal internal fixation for these acetabular fractures. The purpose of this study was to evaluate the biomechanical stability of complex acetabular fractures using a dynamic anterior titanium-plate screw system of the quadrilateral area (DAPSQ) by simulating the standing and sitting positions of pelvic specimens. MATERIALS AND METHODS: Eight formal in-preserved cadaveric pelvises aged 30-50 years were selected as the research objects. First, one hip of the normal pelvises was randomly used as the control model (group B) for measurement, and then one hip of the pelvises was randomly selected to make the fracture model in the 8 intact pelvises as the experimental model (group A) for measurement. In group A, acetabular both-column fractures in the quadrilateral area were established, and the fractures were fixed by DAPSQ. The biomechanical testing machine was used to load (simulated physiological load) from 400 N to 700 N at a 1 mm/min speed for 30 s in the vertical direction when the specimens were measured at random in simulated standing or sitting positions in groups. The horizontal displacement and longitudinal displacement of the acetabular fractures in the quadrilateral area were measured in both the standing and sitting simulations. RESULTS: As the load increased, no dislocation or internal fixation breakage occurred during the measurements. In the standing position, the horizontal displacement of the quadrilateral area fractures in group A and group B appeared to be less than 1 mm with loads ranging from 400 N to 700 N, and there was no significant difference between group A and group B (p > 0.05). The longitudinal displacement appeared to be greater than 1 mm with a load of 700 mm in group A (700 N, 2 cases), and the difference was significant between group A and group B (p < 0.05). In the sitting position, the horizontal and longitudinal displacements of the quadrilateral areas were within 0.5 mm in group A and group B, and there was no significant difference between group A and group B (p > 0.05). CONCLUSION: For complex acetabular fractures in the quadrilateral area, DAPSQ fixation may provide early sitting stability, but it is inappropriate for patients to stand too early.

Mid- to long-term outcomes of proximal humerus fractures treated with open reduction, plate fixation, and iliac bone autograft augmentation.

BACKGROUND: Open reduction and internal fixation (ORIF) using locking plates is a widely adopted treatment for displaced proximal humerus fractures. Various augmentation techniques have been developed to enhance the stability of plate fixation. Among these, iliac bone autograft is notable for its advantages over allografts, such as ready availability and the elimination of costs and risks associated with disease transmission. Despite its potential benefits, data on the outcomes of iliac bone autograft augmentation (IBAA) are still limited. This study aims to present the mid- to long-term results of treating proximal humerus fractures with ORIF using locking plates and IBAA. METHODS: The study included 15 patients treated with ORIF and IBAA. We classified fracture patterns using the Neer classification and estimated local bone density via the deltoid tuberosity index. We measured the neck shaft angle (NSA) and humeral head height (HHH) on both immediate postoperative and most recent X-ray images to assess the maintenance of reduction. Clinical outcomes were evaluated using the DASH (Disabilities of the Arm, Shoulder, and Hand) and Constant scores. RESULTS: The average follow-up duration was 59.56 months, ranging from 24 to 93 months. A majority of fractures were classified as four-part (53%). The average immediate and late postoperative NSAs were 132.6±8.19 and 131.6±7.32 degrees, respectively. The average HHH on the immediate postoperative and latest follow-up images were 16.46±6.07 and 15.10±5.34, respectively. None of the patients exhibited any radiological signs of avascular necrosis or loss of reduction at the latest follow-up. The mean postoperative Constant and DASH scores at the latest follow-up were 79.6 and 11.5, respectively. CONCLUSION: Our findings suggest that ORIF with IBAA is an effective method for managing three- or four-part proximal humerus fractures, yielding excellent outcomes.

Alternate levels versus all levels mini-plate fixation in C3-6 cervical laminoplasty: a retrospective comparative study.

OBJECTIVE: The purpose of this study is to compare radiological and clinical outcomes between alternate levels (C4 and C6) and all levels mini-plate fixation in C3-6 unilateral open-door laminoplasty. METHODS: Ninety-six patients who underwent C3-6 unilateral open-door laminoplasty with alternate levels mini-plate fixation (54 patients in group A) or all levels mini-plate fixation (42 patients in group B) between September 2014 and September 2019 were reviewed in this study. Radiologic and clinical outcomes were assessed. Clinical results included Visual Analogue Scale (VAS) of axial neck pain and Japanese Orthopedic Association (JOA) score. Radiographic results included cervical range of motion (ROM), cervical curvature index (CCI), and the spinal canal expansive parameters including open angle, anteroposterior diameter (APD), and Pavlov`s ratio. RESULTS: There was no significant difference in VAS, JOA score, ROM, and CCI between two groups. There was no significant difference in canal expansion postoperatively between two groups. However, open angle, APD, and Pavlov`s ratio in group A decreased significantly during the follow-up. In group B, APD, Pavlov`s ratio, and open angle were maintained until the final follow-up. There was no hardware failure or lamina reclosure occurred in both groups during the follow-up. The mean cost of group B was higher than that of group A. CONCLUSIONS: Despite the differences in the maintenance of canal expansion, alternate levels mini-plate fixation can achieve similar clinical outcomes as all levels mini-plate fixation in C3-6 unilateral open-door laminoplasty. As evidenced in this study, we believe C3-6 laminoplasty with alternate levels (C4 and C6) mini-plate fixation is an economical, effective, and safe treatment method.

Combining robotics and 3D printing facilitates closed reduction of humeral shaft fractures using a minimally invasive plate as a reduction template: A proof-of-concept study.

BACKGROUND: Minimally invasive percutaneous plate osteosynthesis for humeral shaft fractures (HSFs) has limitations due to malreduction and radiation exposure. To address these limitations, we integrated robotics and 3D printing by incorporating plates as reduction templates. METHOD: The innovative technology facilitated closed reduction of HSFs in the operating theatre using 18 models with cortical marking holes. The dataset of the precontoured plate was imported into 3D planning software for virtual fixation and screw path planning. The models were divided into half to simulate transverse fractures. During the operation, the software generated drilling trajectories for robot navigation, and precise plate installation achieved automatic fracture reduction. RESULTS: The evaluation results of reduction accuracy revealed variations in length, apposition, alignment, and rotation that meet the criteria for anatomic reduction. High interoperator reliabilities were observed for all parameters. CONCLUSIONS: The proposed technology achieved anatomic reduction in simulated bones.

Digital technology revolutionizing mandibular fracture treatment: a comparative analysis of patient-specific plates and conventional titanium plates.

OBJECTIVES: The treatment of fractures prioritizes the restoration of functionality through the realignment of fractured segments. Conventional methods, such as titanium plates, have been employed for this purpose; however, certain limitations have been observed, leading to the development of patient-specific plates. Furthermore, recent advancements in digital technology in dentistry enable the creation of virtual models and simulations of surgical procedures. The aim was to assess the clinical effectiveness of patient-specific plates utilizing digital technology in treating mandibular fractures compared to conventional titanium plates. MATERIALS AND METHODS: Twenty patients diagnosed with mandibular fractures were included and randomly assigned to either the study or control groups. The surgical procedure comprised reduction and internal fixation utilizing patient-specific plates generated through virtual surgery planning with digital models for the study group, while the control group underwent the same procedure with conventional titanium plates. Assessment criteria included the presence of malunion, infection, sensory disturbance, subjective occlusal disturbance and occlusal force in functional maximum intercuspation (MICP). Statistical analysis involved using the Chi-square test and one-way repeated measures analysis of variance. RESULTS: All parameters showed no statistically significant differences between the study and control groups, except for the enhancement in occlusal force in functional MICP, where a statistically significant difference was observed (p = 0.000). CONCLUSION: Using patient-specific plates using digital technology has demonstrated clinical effectiveness in treating mandibular fractures, offering advantages of time efficiency and benefits for less experienced surgeons. CLINICAL RELEVANCE: Patient-specific plates combined with digital technology can be clinically effective in mandibular fracture treatment.

Biomechanical Design Optimization of Distal Humerus Fracture Plates: A Review.

The goal of this article was to review studies on distal humerus fracture plates (DHFPs) to understand the biomechanical influence of systematically changing the plate or screw variables. The problem is that DHFPs are commonly used surgically, although complications can still occur, and it is unclear if implant configurations are always optimized using biomechanical criteria. A systematic search of the PubMed database was conducted to identify English-language biomechanical optimization studies of DHFPs that parametrically altered plate and/or screw variables to analyze their influence on engineering performance. Intraarticular and extraarticular fracture (EAF) data were separated and organized under commonly used biomechanical outcome metrics. The results identified 52 eligible DHFP studies, which evaluated various plate and screw variables. The most common plate variables evaluated were geometry, hole type, number, and position. Fewer studies assessed screw variables, with number and angle being the most common. However, no studies examined nonmetallic materials for plates or screws, which may be of interest in future research. Also, articles used various combinations of biomechanical outcome metrics, such as interfragmentary fracture motion, bone, plate, or screw stress, number of loading cycles to failure, and overall stiffness (Os) or failure strength (Fs). However, no study evaluated the bone stress under the plate to examine bone "stress shielding," which may impact bone health clinically. Surgeons treating intraarticular and extraarticular distal humerus fractures should seriously consider two precontoured, long, thick, locked, and parallel plates that are secured by long, thick, and plate-to-plate screws that are located at staggered levels along the proximal parts of the plates, as well as an extra transfracture plate screw. Also, research engineers could improve new studies by perusing recommendations in future work (e.g., studying alternative nonmetallic materials or "stress shielding"), clinical ramifications (e.g., benefits of locked plates), and study quality (e.g., experimental validation of computational studies).

Intramedullary Fixation Versus Plate Fixation of Distal Fibular Fractures: A Systematic Review.

INTRODUCTION: The purpose of this systematic review and meta-analysis was to provide an update of the recent literature comparing clinical outcomes of surgically treated fibular fractures using intramedullary nailing (IMN) with open reduction and internal plate fixation (ORIF). METHODS: A literature search reporting clinical outcomes after IMN or ORIF of the distal fibula was conducted on PubMed. Inclusion criteria consisted of original studies; studies focusing on clinical outcomes after IMN or IMN and ORIF published before May 11, 2022; studies with at least 5 patients; and studies reporting union rates, complication rates, and patient-reported outcomes such as American Orthopaedic Foot and Ankle Society (AOFAS) and Olerud-Molander scores. RESULTS: Of 2,394 studies identified, a total of 29 studies (4 LOE-I, 2 LOE-II, 6 LOE-III, 17 LOE-IV) were included consisting of 1,850 IMN patients and 514 plate patients. The pooled mean age of IMN patients was 58 years (95% confidence interval [CI], 54 to 62, I2 = 42%) versus 57 years (95% CI, 53 to 62, I2 = 49%) in ORIF. Union rates for IMN patients revealed a 99% union rate (95% CI, 0.98 to 1.00, I2 = 20%) versus 97% union rate for ORIF patients (95% CI, 0.94 to 0.99, I2 = 0%). Studies that compared IMN with ORIF revealed no difference in union rates (risk ratio [RR] = 0.99, 95% CI, 0.96 to 1.02, I2 = 0%). IMN patients showed a 15% complication rate (95% CI, 0.09 to 0.23, I2 = 89%), whereas plate patients had a complication rate of 30% (95% CI, 0.18 to 0.46, I2 = 63%). When comparing studies with both treatments, IMN patients had a significantly lower risk of complications (RR = 0.49, 95% CI, 0.29 to 0.82, I2 = 50%). The IMN group trended toward a higher mean AOFAS and Olerud-Molander score than the plate group by 4.53 (95% CI, -14.58 to 23.65, I2 = 85%) and 3.54 (95% CI, -2.32 to 9.41, I2 = 76%) points, respectively. CONCLUSION: Current literature reveals near equivalence in union rates and a markedly lower risk of complications when comparing IMN with plate fixation. While IMN patients had higher AOFAS and Olerud-Molander scores, these differences were not statistically significant. Notably, subgroup analyses indicated that rates of symptomatic implant and removal of implant were comparable between IMN and ORIF, which may indicate that wound-related complications were reduced in the minimally invasive IMN technique. While the high cost of IMN implants remains a barrier to their widespread adoption, the long-term benefits of reducing complications, specifically associated with wound complications in high-risk populations, may greatly improve quality of care for patients with distal fibula fractures. Additional research and cost-effectiveness analyses are warranted to fully assess the long-term benefits and economic feasibility of using IMN fixation for distal fibula fractures. LEVEL OF EVIDENCE: Therapeutic Level IV.

Efficacy comparison between intramedullary nail fixation and plate fixation in distal tibia fractures: a meta-analysis of randomized controlled trials.

BACKGROUND: Intramedullary nail (IMN) and plate fixation are the most commonly used surgical modalities for distal tibia fractures. However, the superiority of their efficacy regarding functional outcomes and complications remains controversial. Here, we performed a systematic review and meta-analysis to compare the efficacy of these two modalities. METHODS: Randomized controlled trials (RCTs) comparing the efficacy of IMN and plate fixation in distal tibia fractures were searched in PubMed, Web of Science, EMBASE, ClinicalTrials.gov, and Cochrane Library up to January 31, 2024. Weighted mean difference (WMD) and odds ratio (OR) with corresponding 95% confidence interval (CI) were estimated using a random-effect model for continuous and categorical outcomes, respectively. RESULTS: A total of 20 RCTs comprising 1528 patients were included. Compared with plate fixation, IMN significantly shortened surgery time (WMD=-10.73 min, 95%CI: -15.93 to -5.52), union time (WMD=-1.56 weeks, 95%CI: -2.82 to -0.30), and partial (WMD=-1.71 weeks, 95%CI: -1.91 to -0.43) and full (WMD=-2.61 weeks, 95%CI: -3.53 to -1.70) weight-bearing time. IMN was associated with markedly reduced risk of wound infection (OR = 0.44, 95%CI: 0.31-0.63) and secondary procedures (OR = 0.72, 95%CI: 0.55-0.95), but increased the risk of malunion (OR = 1.53, 95%CI: 1.02-2.30) and anterior knee pain (OR = 3.94, 95%CI: 1.68-9.28). The rates of nonunion, delayed union, and functional assessment scores did not significantly differ between the two groups. The percentages of patients obtaining an excellent functional outcome or an excellent and good functional outcome post-operation were comparable. CONCLUSIONS: Both IMN and plate fixation are effective modalities for the surgical treatment of distal tibia fractures. IMN seems to be preferred since it confers more advantages, but the elevated rates of malunion and knee pain require attention. The decision on fixation modality should be tailored to the specific fracture, considering these pros and cons.

Staples, tension-band plates, and percutaneous epiphysiodesis screws used for leg-length discrepancy treatment: a systematic review and proportional meta-analysis.

BACKGROUND AND PURPOSE: The primary aim of this systematic review and meta-analysis was to evaluate the success rate of 3 different epiphysiodesis techniques with implant usage for the treatment of leg-length discrepancy (LLD) in the pediatric population. The secondary aim was to address effectiveness (final LLD) and the reported complications of staples, tension-band plates (TBP), and percutaneous epiphysiodesis screws (PETS). METHODS: In this systematic review we searched MEDLINE (PubMed), Embase, Cochrane Library, Web of Science and Scopus for studies on skeletally immature patients with LLD treated with epiphysiodesis with an implant. The extracted outcome categories were effectiveness of epiphysiodesis (LLD measurements pre-/postoperatively, successful/unsuccessful) and complications that were graded on severity. RESULTS: 44 studies (2,184 patients) were included. 455 underwent epiphysiodesis with PETS, 578 patients with TBP, and 1,048 with staples. Successful epiphysiodesis was reported in 76% (95% confidence interval [CI] 61-89) with PETS (9 studies), 67% (CI 54-79) with TBP (10 studies), and 51% (CI 28-65) with Blount staples (8 studies). From pooled analysis, the severe complications rate was 7% for PETS, 17% for TBP, and 16% for Blount staples. Angular deformity was reported in 4% after PETS, 10% after TBP, and 17% after Blount staples. CONCLUSION: Our results showed that epiphysiodesis with PETS implants was the most successful technique. PETS had a higher success rate, fewer severe complications, and a lower proportion with angular deformity.

[Application of reverse traction device in preoperative treatment of high-energy tibial plateau fracture].

Objective: To investigate the effectiveness of the reverse traction device in the preoperative treatment of high-energy tibial plateau fractures. Methods: A retrospective study was conducted to analyze the clinical data of 33 patients with high-energy tibial plateau fractures who met the selection criteria between December 2020 and December 2023. All patients were treated by open reduction and internal fixation. According to the preoperative traction method, they were divided into the observation group (16 cases, treated with a reverse traction device on the day of admission) and the control group (17 cases, treated with heel traction on the day of admission). There was no significant difference in baseline data such as gender, age, body mass index, affected side, cause of injury, fracture Schatzker classification between the two groups ( P>0.05). Preoperative waiting time, preoperative related complications (nail channel loosening, nail channel oozing, nail channel infection, soft tissue necrosis, soft tissue infection, deep vein thrombosis of the lower extremity, etc.), operation time, and total hospitalization time were recorded and compared between the two groups. On the 4th day after traction, visual analogue scale (VAS) score was used to evaluate the pain relief of the patients, the swelling value of the affected limb was measured, and the Immobilization Comfort Questionnaire (ICQ) score was used to evaluate the perioperative hospital comfort of the patients. Results: Both groups of patients completed the operation successfully, and the operation time, total hospitalization time, and preoperative waiting time of the observation group were significantly less than those of the control group ( P<0.05). There was no preoperative related complications in the observation group; in the control group, 3 patients had nail channel loosening and oozing, and 2 cases had the deep vein thrombosis of the lower extremity; the difference in the incidence of complication between the two groups was significant ( P<0.05). On the 4th day after traction, the ICQ score, VAS score, and limb swelling value of the observation group were significantly better than those of the control group ( P<0.05). X-ray films showed that the tibial plateau fracture separation and lower limb alignment recovered after calcaneal traction in the control group, but not as obvious as in the observation group. The fracture gap in the observation group significantly reduced, the tibial plateau alignment was good, and the lateral angulation deformity was corrected. Conclusion: The use of reverse traction treatment in patients with high-energy tibial plateau fractures on admission can accelerate the swelling around the soft tissues to subside, reduce patients' pain, shorten the preoperative waiting time, improve the patients' preoperative quality of life, and contribute to the shortening of the operation time, with a good effectiveness.

Management of infected bone defects of the femoral shaft by Masquelet technique: sequential internal fixation and nail with plate augmentation.

BACKGROUND: To evaluate the effectiveness of a sequential internal fixation strategy and intramedullary nailing with plate augmentation (IMN/PA) for bone reconstruction in the management of infected femoral shaft defects using the Masquelet technique. METHODS: We performed a retrospective descriptive cohort study of 21 patients (mean age, 36.4 years) with infected bone defects of the femoral shaft treated by the Masquelet technique with a minimum follow-up of 18 months after second stage. After aggressive debridement, temporary stabilisation (T1) was achieved by an antibiotic-loaded bone cement spacer and internal fixation with a bone cement-coated locking plate. At second stage (T2), the spacer and the locking plate were removed following re-debridement, and IMN/PA was used as definitive fixation together with bone grafting. We evaluated the following clinical outcomes: infection recurrence, bone union time, complications, and the affected limb's knee joint function. RESULTS: The median and quartiles of bone defect length was 7 (4.75-9.5) cm. Four patients required iterative debridement for infection recurrence after T1. The median of interval between T1 and T2 was 10 (9-19) weeks. At a median follow-up of 22 (20-27.5) months, none of the patients experienced recurrence of infection. Bone union was achieved at 7 (6-8.5) months in all patients, with one patient experiencing delayed union at the distal end of bone defect due to screws loosening. At the last follow-up, the median of flexion ROM of the knee joint was 120 (105-120.0)°. CONCLUSIONS: For infected femoral shaft bone defects treated by the Masquelet technique, sequential internal fixation and IMN/PA for the reconstruction can provide excellent mechanical stability, which is beneficial for early functional exercise and bone union, and does not increase the rate of infection recurrence.

Finite element analysis of the treatment of a minimally invasive approach combined with a novel anatomical locking plate for scapular body fractures.

BACKGROUND: The minimally invasive approach for the treatment of displaced scapular neck or body fractures has the advantages of less trauma and minimal muscle dissection. In clinical practice, the minimally invasive approach combined with an anatomical locking plate has been used to treat scapular body fractures. In addition, we have made minor modifications to the minimally invasive approach. However, the biomechanical study about the approach combined with an anatomical locking plate in treating scapular body fractures was limited. METHODS: Finite element analysis (FEA) was used to conduct the biomechanical comparison between the anatomical locking plate (AP model) and reconstructive plate (RP model) in the treatment of scapular body fractures through the modified minimally invasive approach. A healthy male volunteer with no history of scapula or systemic diseases was recruited. High-resolution computed tomography images of his right scapula were obtained. Two scapula models were constructed and analyzed by the software of Mimics 21.0, Geomagic Wrap 2021, SolidWorks 2021, and ANSYS Workbench 2022, respectively. RESULTS: Through static structural analysis, in terms of equivalent von Mises stress, equivalent elastic strain, and total deformation, the AP model exhibited superior safety characteristics, enhanced flexibility, and anticipated stability compared with the RP model. This was evidenced by lower maximum stress, lower maximum strain and displacement. CONCLUSION: The minimally invasive approach combined with an anatomical locking plate for scapular body fractures had better biomechanical stability. The study provided a biomechanical basis to guide the clinical treatment of scapular body fractures.